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In canine mast cell tumours (MCTs), distant metastasis (DM) occurs infrequently. However, high-risk MCTs or tumours with certain negative prognostic factors (NPFs) are those more prone to develop metastatic disease. Accordingly, a thorough workup might not be necessary for MCTs lacking NPFs. The objective of this study was to evaluate the rate of DM and, therefore, the benefit of extensive staging in dogs presenting with and without NPFs. Furthermore, the association between the selected NPFs and DM was assessed, and factors that may have influenced outcome were evaluated. Dogs presenting with at least one NPF (Patnaik III/Kiupel high-grade, LN metastasis, rapid growth, ulceration, recurrence, high-risk location) were defined as high-risk and without as low-risk MCTs. Ninety-nine dogs were included, with 49% of MCTs in the high-risk and 51% in the low-risk group. All seven dogs with DM were identified in the high-risk group; 43% were Patnaik III/Kiupel high-grade tumours. The median survival time (MST) for this subgroup was 84 days. Patnaik III/Kiupel high-grade and rapid growth were NPFs significantly associated with DM at staging. Furthermore, a significant difference (p < .001) in MST was demonstrated between the high-risk and low-risk groups (899 days vs. not reached). NPFs significantly associated with outcome were rapid growth, presence of DM at staging, and surgical tumour excision. These results indicate that extensive staging in the absence of NPFs does not seem to be beneficial. On the other hand, by using the selected NPFs, a subset of MCTs prone to DM can be identified.

Objective: Analysis of preoperative predictors for pituitary adenoma operations and their impact on results after endoscopic endonasal transsphenoidal surgery (EETSS) Methods: We carried out a prospective study of all the patients (99), who were endoscopically endonated transphenoidal at the Department of Neurosurgery, Benha University, Egypt and Wuhan Union Hospital, and China between January 2018 and December 2019. Medical data were gathered and evaluated, including information on sex, age, tumour size, hormone level, preoperative MRI brain and sella, resection scope, result (clinical and endocrinological) and complications. Results: 99 patients with PA were endoscopic transsphenoidal endonasal treatments, 52 males (52.5%) and 47 females (47.5 percent ). Average age 42.5 ± 11.2 years, Irregular menstrual behaviour was the highest in the study populations in 22 patients, followed by visual disturbance in 17 patients (17.2%), acromegaly and increased intracranial pressure in 14 patients, followed by 11 (11.1%), 8 (8.1%) accidents, and 5 (8.1%) cases (11.1%), followed by headache with 11 (12.1%). Conclusion: the size and scope of the tumour excision are only important postoperative determinants (hormonal, radiological & postoperative complications).

Carcinoma tongue is one of the commonest cancer of head and neck in India. Various pedicled and free flaps have been used to reconstruct the tongue defect following glossectomies. In this era of free flaps various loco- regional pedicled flaps have been overlooked and infrahyoid flap is one of them. This flap meets the functional and cosmetic acceptance of the tongue defect reconstruction with minimal morbidity to the donor site. This paper presents author’s experience of using infrahyoid flap in 10 patients of carcinoma tongue. In all the patient’s tongue defect was closed with the infrahyoid flap, in 1 case flap necrosed fully and in 1 partially. Functional outcome and quality of life in all the patients were acceptable.

Background Extensor mechanism function after a proximal tibial tumour excision is the major determining factor for the limb function. However, problems of extensor lag, delayed healing and poor functional outcomes exist with the previous methods of its reconstruction. We describe a novel technique of using a patellar stainless steel (SS) wire to reconstruct the extensor apparatus of the knee in non-porous coated implants and examine the functional outcome and associated complications. Methods This was a retrospective analytical interventional study. Twenty-six patients operated between 2011 and 2019 were included. Extensor lag measured at 6 months and 12 months postoperative, total range of motion at 12 months and Musculoskeletal Tumor Society (MSTS) score at the final visit were retrieved. Complications that occurred during the follow up period were noted. Patellar position was measured using comparative patellar-position-ratio. Results Mean extensor lag at 6 months was 18.5° which improved to 8.7° at 12 months. Patellar malposition and deep infection were found to be the causes of poor functional outcome. A patellar-position-ratio between 0.9 and 1.1 led to a well-functioning extensor apparatus. Four patients underwent above-knee amputations. Deep infection and amputations reduced the MSTS score. An SS wire give way after 6 months did not affect the extensor power. A medial gastrocnemius flap reduced the infection rates. Conclusion Patellar SS wiring is an effective technique for reconstructing the knee extensor apparatus following a proximal tibial tumour excision mega-prosthesis. Proper position of the SS wire prevents wire-related complications. For a well-functioning extensor apparatus, use of a gastrocnemius flap cover intra-operatively is pertinent along with lack of infection for a pain-free, stable and mobile limb.

Scalp defects commonly occur as a result of tumour excision or trauma. The reconstruction of medium to large defects can be challenging due to the scalp laxity and hair growth pattern. We compare the outcome of patients who have had snail flap reconstruction in comparison to skin grafts. We conducted a retrospective case study of 45 consecutive patients’ over a 3-year period (2016–2018), across three sub-groups, viz. Fibonacci sequence flap, split skin graft and full-thickness skin grafts. The sub-cohorts were all matched for age, sex, indications and defect sizes before being analysed in terms of complication rates and wound healing rates over a 4-month period. The Fibonacci ‘snail’ flap was found to heal significantly faster than the full-thickness skin graft group and with lower complication rates overall, compared to skin grafts, but the latter outcome did not reach statistical significance. The aesthetic outcome of the Fibonacci flap though was superior to skin grafts both in terms of colour and contour match as well as hair restoration. The Fibonacci ‘snail’ flap is a sound option for the reconstruction of medium to large size defects of the scalp, even in those with poor performance scores, especially since its lower flap: defect ratio allows it to be performed under local anaesthesia. The advantage of the ‘snail’ flap over other scalp flaps will be determined in a future comparative study. Level of evidence: Level III, therapeutic study.

OBJECTIVES Chest wall sarcomas are rare, aggressive malignancies, the management of which mainly revolves around surgery. Radical tumour excision with free margins represents the optimal treatment for loco-regional clinically resectable disease. The objective of this study was to review our 11-year experience with chest wall resection for primary and metastatic sarcomas, focusing on surgical techniques and strategies for reconstruction. METHODS Retrospective analysis of a comprehensive database of patients who underwent chest wall resection for primary or secondary sarcoma at our Institute from January 2009 to December 2019. RESULTS Out of 26 patients, 21 (81%) suffered from primary chest wall sarcoma, while 5 (19%) had recurring disease. The median number of resected ribs was 3. Sternal resection was performed in 6 cases (23%). Prosthetic thoracic reconstruction was deemed necessary in 24 cases (92%). Tumour recurrence was observed in 15 patients (58%). The median overall survival was 73.6 months. Primary and secondary tumours showed comparable survival (P = 0.49). At univariate analysis, disease recurrence and infiltrated margins on pathological specimens were associated with poorer survival (P = 0.014 and 0.022, respectively). In patients with primary sarcoma, the median progression-free survival was 13.3 months. Associated visceral resections were significantly associated to postoperative complications (P = 0.02). CONCLUSIONS Chest wall resection followed by prosthetic reconstruction is feasible in carefully selected patients and should be performed by experienced surgeons with the aim of achieving free resection margins, resulting in improved long-term outcomes.

Purpose: The purpose of this study was to compare the effectiveness of endoscopic vs microscopic excision of pituitary noninvasive adenoma.Materials and Methods: The current prospective comparison study was carried out at the Department of Neurology, Apex Hospital, Jaipur, Rajasthan, India among 40 patients who had been diagnosed with noninvasive pituitary adenoma Group I (n=22) had endoscopic trans-sphenoidal surgery performed on them. Group II (n=18) had trans-sphenoidal surgery using a microscopic approach.Results: An overall total of 40 individuals with pituitary nodules had transsphenoidal surgery as a result of this study. Endonasal endoscopic trans-sphenoidal surgery (Group I) was performed on 22 patients, whereas microscopic trans-sphenoidal surgery (Group II) was performed on 18 patients (group II). Complete tumour excision was accomplished in 14 (63.6 percent) of the patients in group I, while it was achieved in 10 (55.6 percent) of the patients in group II.Conclusion: Both techniques are valid for the treatment of pituitary noninvasive adenomas. However, endoscopy proves to be superior for resection followed by less post-operative complication in comparison to microscopic technique.

Introduction Due to a relatively high recurrence rate of facial basal cell carcinoma (BCC), its morbidity is very significant. Aim To analyse the expression of α-SMA, E-cadherin, Ber-Ep4 and MOC-31 as predictors of local recurrence in a group of patients with primary and recurrent BCCs of the face in correlation with histological and clinical data. Material and methods The study cohort included 79 patients with facial BCC (52 with primary BCC and 27 with recurrent BCC) who were treated at the Department of Cranio-Maxillofacial Surgery of the Jagiellonian University, Krakow in 1997-2009. Results Significant risk factors for local recurrence included: recurrent tumour (p = 0.001), multifocal BCC (p = 0.01), incomplete tumour excision (p = 0.02) and the aggressive infiltrating histologic subtype of BCC (p = 0.05). In the group of primary BCCs, positive expression of stromal α-SMA (p = 0.03) correlated with a statistically significant higher recurrence rate and so did positive expression of α-SMA in tumour cells of recurrent BCC (p = 0.002). In the group of primary aggressive BCC subtypes, reduced expression of MOC-31 was also associated with a higher rate of relapse (p = 0.02). Conclusions Our findings provide information about α-SMA and MOC-31 expression in primary and recurrent BCCs. These data may contribute to the formulation of a more targeted treatment plan and follow-up strategy for patients with facial basal cell carcinoma.

BACKGROUND A 65-year-old female patient with a histologically confirmed basal cell carcinoma located at the right lateral lower eyelid was referred for surgical tumour excision and reconstruction of the periorbital area. The periocular zone was reconstructed in a two-staged procedure with bilamellar repair of both eyelids. An autologous chondral graft, mucosal advancement techniques and a periosteum-temporalis fascia hinged turnover flap were used for reconstruction of the posterior lamellae. A modified Tenzel flap and a paramedian forehead flap were used for reconstruction of the anterior lamellae. An acceptable functional and aesthetic outcome of the reconstruction was achieved.

The current pool of organs available for transplantation does not cover requirements, for this reason non-standard risk donors need to be incorporated into the pool. In this way, donors with small renal tumour are considered for transplantation after bench tumour excision. The aim of our study was to analyse our experience in using these grafts for transplantation. Retrospective analysis from our prospective accrued database of donors with incidental renal mass used for kidney transplantation between January 2007 and August 2018. Twenty kidney transplantations were performed, thirteen cases received the affected kidney (after tumour removal) and seven the contralateral kidney; from six living and eleven deceased donors. Donor and recipient median age was 58 years (range 22–82) and 56.5 years (range 38–74), respectively. Mean tumour diameter was 12.7 mm (SD 9.5). Tumours resulted in two benign lesions and fifteen renal cell carcinoma. Surgical margins were negative. Two cases presented with bleeding after reperfusion was solved without repercussion. One case presented with immediate vein thrombosis. None of them present delayed graft function. After a 69 month follow-up none of the donors or the recipients presented tumour recurrence. Kidneys with small incidental tumours seem to be a good option for kidney transplantation in selected patients after bench surgery excision with good functional and oncologic results. More studies and longer follow-up are needed to confirm these results.

Benign bone tumours of the hand are frequently seen by hand surgeons and may cause symptoms or result in pathological fracture. These tumours are usually managed with surgical curettage with, or without, grafting. The surgical approach is determined by the geometry of the tumour and the affected bone, and by the surrounding soft tissue envelope. Whilst curettage of the tumour can be undertaken openly, potentially with the assistance of fluoroscopy, the addition of endoscopy to visualise the tumour cavity (osteoscopy) can aid in tumour removal and makes complete tumour removal more certain. This chapter describes the author’s technique of endoscopic benign tumour excision in hand.

Large bone defects resulting from musculoskeletal tumours, infections, or trauma are often unable to heal spontaneously. The challenge for surgeons is to avoid amputation, and provide the best functional outcomes. Allograft, vascularized fibular or iliac graft, hybrid graft, extracorporeal devitalized autograft, distraction osteogenesis, induced-membrane technique, and segmental prostheses are the most common surgical strategies to manage large bone defects. Given its optimal osteogenesis, osteoinduction, osteoconduction, and histocompatibility properties, along with the lower the risk of immunological rejection, autologous graft represents the most common used strategy for reconstruction of bone defects. However, the choice of the best surgical technique is still debated, and no consensus has been reached. The present study investigated the current reconstructive strategies for large bone defect after trauma, infections, or tumour excision, discussed advantages and disadvantages of each technique, debated available techniques and materials, and evaluated complications and new perspectives.

ObjectiveSinonasal inverted papillomas are challenging benign tumours of the nasal cavity because of their high recurrence rates and the lifetime malignant transformation risk of 10 per cent as well as their locally aggressive behaviour. This study aimed to describe treatment strategies for inverted papillomas with intracranial or intraorbital involvement.MethodThis was a prospective case series study of 18 patients with inverted papilloma with intracranial or intraorbital involvement. Patient demographic data, imaging, pathology, surgical technique and recurrences were recorded prospectively over a period of seven years.ResultsA total of 83 per cent of the patients in this study had been previously operated on, consisting of 8 cases with intracranial involvement, 1 case with intraorbital involvement and 9 with both. During follow up with a medium of 37 months (range, 13–115 months) there were two recurrences.ConclusionIt was postulated that intracranial or intraorbital involvement observed in this series was the result of multiple revisions. However, using accurate imaging protocols and the pedicle-oriented approach for tumour excision, complete tumour removal was achieved in most cases with minimal post-operative complications.

We describe a case of an extremely rare intrathoracic supradiaphragmatic accessory liver tissue that was excised via transdiaphragmatic uniportal video-assisted thoracoscopic surgery. The intrathoracic mass that was radiologically detected was found to be mimicking a pleural tumour because of its supradiaphragmatic location as well as the presence of a clear cleavage plane separating the mass and the liver completely. This, to our knowledge, is the first described case that was resected via transdiaphragmatic uniportal approach in the literature.

Objectives To analyse the long-term outcome of small margin (up to 2 mm) excision of clinically well-demarcated primary periocular basal cell carcinomas (BCCs). Methods Retrospective evaluation of 185 patients with excised well-demarcated primary BCCs at a minimum of 11 years following excision. All patients underwent tumour excision with maximum margins of 2 mm. Resulting defects were, if possible, closed directly. Reconstruction requiring flaps or grafts was delayed until receipt of the histological report, which was obtained in all cases. Results Of 185 patients evaluated, 69 (37.3%) were still alive at the time of the study, at least 11 years post excision. One-stage excision and direct closure was performed in 60/69 patients (86.96%). In 9/69 patients (13.04%), excision was undertaken with reconstruction 4 days later, after receipt of the histopathology report. Histological assessment confirmed complete initial excision in 59/69 patients (85.5%) rising to 68 (98.6%) after two excisions. Mean follow-up was 13 years, with no recurrence in the living cohort. Three deceased patients had a recurrence, one of whose tumour was reported histologically as incompletely excised but declined further surgery, giving an overall recurrence rate of 3/185 (1.62%). For patients who completed treatment, the recurrence rate was 2 in 184 (1.09%). Six of the sixty-nine patients (8.7%) developed new tumours on the contralateral eyelid or the forehead. Conclusions Primary, clinically well-demarcated periocular BCCs can be safely treated using small (up to 2 mm) excision margins in a one-stop setting with immediate reconstruction for those defects which can be closed directly without recourse to flaps or grafts. Synopsis A retrospective study of 185 patients who had small margin (≤2 mm) excision of clinically well-demarcated primary periocular BCCs demonstrated a recurrence rate of 3/185 (1.62%) at a minimum of 11 years' follow-up.

We describe here the first dorsal metacarpal artery propeller perforator flap, used to cover a full thickness, radiopalmar defect of the index finger after tumour excision. By associating a propeller design to the dissection of the first metacarpal pedicle, this flap can be effective in coverage of proximal index and web space defects, with primary closure and pleasant aesthetic outcomes. Harvested together with a superficial sensory branch from the radial nerve, this flap can provide effective coverage and sensory recovery.

Distal Fibula Giant cell tumour (GCT) is a rare condition. The described methods of treatment for distal fibula GCT include excision of tumour and ankle arthrodesis, replacement of distal fibula with ipsilateral proximal fibula and autograft or allograft reconstruction. This case report describes treatment of distal fibula grade 3 GCT with involvement of syndesmosis with tumour excision, proximal fibular slide and reconstruction of ankle joint. With this technique the ankle joint movements are preserved and stability is maintained.

Objectives Although the reliability of frozen sections for the intraoperative assessment of complete tumour excision has been established, the best location for collection and the impact of the type of sampling are still debated. We retrospectively investigated the reliability of frozen sections when collected from the surgical bed as tissue strips representative of the whole superficial margin and as a bowl of tissue underlying the resection site for deep margin, and the possibility of relying on frozen section negativity to consider resections complete. Materials and methods Frozen section reliability was calculated by comparing histology before and after formalin embedding and then categorised by sampling type, in 182 patients undergoing transoral resection of oral cancer. Results Comparing frozen and permanent histology, sensitivity, specificity and accuracy were 69%, 98% and 96%, respectively; categorisation by sampling type failed to produce statistically significant differences. Based on frozen section negativity after formalin embedding, complete resections were obtained in 91.7% of patients with multiple-strip and bowl frozen sections. Conclusion Frozen sections collected as tissue strips and bowl are as reliable as point sampling in the intraoperative guidance of surgical resections. They effectively provide for margin enlargement, thereby increasing the surgeon's confidence that negative margins are clear.

BACKGROUND Reconstruction of palate defects following tumour ablative surgery can be a challenging problem. Different methods have been suggested over the time for the reconstruction of postoperative palatal defects. Since the first report of the Bichat fat pad flap in1977, it has become one of the most commonly used flaps for the reconstruction of palate after tumour excision. We report our results using the tunnellized Bichat fat pad (BFP) flap for 23 cases of palate reconstruction after minor salivary glands tumour excision. METHODS The Authors performed a tunnellized bichat fat pad flap for primary reconstruction of small- medium-sized surgical defects of the palate in 23 patients suffering from minor salivary glands palatal tumors in the period between 2016 and 2019. Each case was reviewed for primary pathologic findings, wound healing, postoperative complications. RESULTS All 23 tunnellized BFP procedures showed excellent recovery and uneventful follow-up. With this technique after 12 months follow-up complete wound healing after only 4 weeks without complication was observed. CONCLUSIONS The tunnellized BFP flap is useful, easy, and uncomplicated new alternative method for primary reconstruction of small to medium-sized palatal surgical defects, that can be performed with a very low morbidity. Submucosal tunnel for the pedicle passage introduced by the Authors adds some advantages in final outcomes with less discomfort for the patients, proving to be a technique able to adds itself to surgical reconstructive technique available today.

Cerebello‑Pontine Angle (CPA) surgeries are very challenging for neurosurgeons as it lies very close to brain stem so various cranial nerves are at risk of damage. Generally, such surgeries require neuromuscular monitoring of various cranial nerves. For that we have to discontinue neuromuscular blocking agents and inhalational agents. Total Intravenous Anaesthesia (TIVA) avoids the use of neuromuscular blocking agents as well as inhalational agents. However, prolonged infusion of propofol is associated with risks, such as hypotension, delayed awakening, and metabolic acidosis, known as “Propofol Infusion Syndrome”. Dexmedetomidine now‑a‑days is used very commonly as an adjuvant to propofol and it significantly reduces the anaesthetic requirement. Addition of dexmedetomidine provides haemodynamic stability during such neurosurgeries. Here, authors have described anaesthetic management of a 46‑year‑old female patient posted for CPA excision along with seventh cranial nerve monitoring using dexmedetomidine with propofol.

Early-stage oral squamous cell carcinoma is treated preferably by wide local tumour excision along with elective neck dissection. The conventional neck dissection leaves an unaesthetic scar, which remains a major challenge that adversely impacts patient satisfaction, their social interactions, and quality of life (QoL). In recent times, retroauricular assisted endoscopic and robotic neck dissection techniques that avoid unaesthetic neck scars have gained popularity. The pitfalls in attaining universal acceptance of these techniques are the need for specialized instrumentation, training, and increased costs. The need for an endoscope or robotic camera when using the retroauricular approach arises mainly while addressing the level I lymph nodes, due to poor access. A combination of transoral and retroauricular approaches that overcomes these factors is presented here, named the transoral retroauricular neck dissection (TREND). The technique successfully avoids a visible neck scar while providing adequate exposure of level I lymph nodes without the need for specialized instrumentation. This approach has been applied, with adequate lymph node clearance achieved in all patients. This novel combination approach of neck dissection is oncologically safe, easy to replicate, and improves patient aesthetics, functional outcomes, and QoL. We recommend that clinicians practice this simple technique and enhance the practice of remote access neck dissection.

Soft tissue sarcomas (STS) are a group of rare malignant tumours that can occur at almost any anatomical location in patients of any age, which often present to health care professional working outside a recognised sarcoma service. A review of foot and ankle STSs was conducted, reporting on patient and tumour characteristics, and patient outcome following surgery performed within and outside our sarcoma service.A retrospective review of all foot and ankle STSs managed by our sarcoma service over a 14 year period was performed. Patient demographics, tumour characteristics, management and patient outcomes including recurrence rates and survival were analysed.Twenty-six patients were analysed (16F:10M) with a mean age of 57.7 years (range 17-87). The mean follow-up was 6.3 years (range 1-16). Sixteen tumours involved the foot, nine the ankle, and one spanned the foot and ankle. Mean tumour size was 4.3 cm (range 0.8-15), although 61% of cases were smaller than 4 cm, and almost one third of cases smaller than 1 cm. Seven of 26 (27%) cases were diagnosed after an unplanned excision performed by non sarcoma surgeons. These patients were more likely to undergo an incomplete tumour excision (p0.001), suffer local recurrence (p = 0.001), and eventually undergo a secondary amputation (p = 0.034) than those patients managed exclusively by a sarcoma service. Overall, 12 (46%) patients died of their disease during follow up, equating to a five-year survival rate of 69%.Our data shows that unplanned excisions continue to be performed on foot and ankle STSs, and that these have detrimental effects on patients. Despite this, our results also show that these complex patients can be managed successfully when referred appropriately to a sarcoma service, prior to any surgical treatment. This highlights the importance of vigilance amongst all health care professionals managing any foot or ankle lumps, regardless of their size.

Background. Intraoperative frozen section (IFS) is often utilised in the surgical treatment of nonmelanocytic skin cancer (NMSC) in sensitive facial regions when Mohs micrographic surgery (MMS) is not available. Objective. To compare the outcome of NMSC patients with excision performed with and without IFS. Materials and Methods. A retrospective, single-centre study was performed on all patients who had undergone resection of NMSC with and without IFS control at the National University Hospital (NUH) from 2010 to 2015. Results. 116 patients were recruited, of which 86 had IFS and 30 did not. The complete excision rate of patients with IFS was higher at 87.2% ( p = 0.0194 ), need for secondary operation was lower at 1.2% ( p = 0.005 ), and need for postsurgery radiotherapy or chemotherapy was lower at 1.2% ( p = 0.001 ). The average duration of surgery in patients who underwent IFS was 95.4 minutes compared to 70.1 minutes in cases which did not undergo IFS. Conclusion. Our study showed an increased complete excision rate and reduced need for secondary surgeries and adjuvant therapy in patients with IFS. However, a longer operative duration was required. Use of IFS may be useful in patients with NMSC lesions in sensitive regions requiring complex reconstruction after tumour excision.

Vascularized composite tissue allotransplantation (VCA) is the youngest field in organ transplantation and refers to the transplantation of anatomical structures with multiple tissue types. VCA has significantly expanded the surgical armamentarium and has enabled the reconstruction and restoration of body parts after devastating trauma, amputation, tumour excision, and congenital malformation. However, VCA has also brought new challenges pertinent to immunosuppression, related to the varying immunogenicity of VCA tissues. Furthermore, VCA has triggered ethical issues and debate.

Objective: The aim of this study was to present our experience with a kite flap in reconstruction of facial wounds after malignant tumour excision. Method: From October 2008 to September 2017, patients with facial malignant tumour were treated in the Xinjiang Uygur Autonomous Region Bazhou People's Hospital with kite flaps after complete excision. The survival rate, colour, cicatrix of the flap and patient satisfaction were recorded after surgery. Results: A total of 95 patients were included in the study. During follow-up, from six months to 8 years, all the kite flaps achieved primary closure and survived well, and the colour and texture were similar to the surrounding skin with no obvious scar. Dysfunction, complications and recurrence had not been reported. Conclusion: The kite flap may be a good option in reconstructing facial wounds after malignant tumour excision (diameters 1–5cm). It is a simple surgical method with sufficient blood supply and extensive adaptability. For patients in this study, no obvious scars were formed and the recipient site matched well with the donor site.

Leiomyosarcoma of the renal vein is a rare tumor of complex diagnosis. We present a case of renal vein leiomyosarcoma in a patient presented with left flank pain. The patient underwent radical nephrectomy with tumour excision.

Twenty-one patients underwent excision of a Campanacci grade III giant cell tumour of the distal radius and had reconstruction using a proximal fibula autograft. We compared the functional results of wrist arthrodesis versus arthroplasty. All 21 patients healed in an average of 8 months, and all have remained disease free. The Musculoskeletal Tumor Society 93, the Disabilities of the Arm, Shoulder, and Hand scores and the grip strength of the operated wrist compared with the contralateral wrist were 93%, 7, and 71% for the arthrodesis group and 83%, 17, and 40% for the arthroplasty group. Arthrodesis of the reconstructed radiocarpal joint provided better grip strength and functional outcomes than arthroplasty.Level of evidence: III

Aims and Objective: The aim of the present article is to highlight how reconstruction with free flaps is different and difficult in cases with robotic head-and-neck cancer surgery. It also highlights the technical guidelines on how to manage the difficulties. Materials and Methods: Eleven patients with oropharyngeal cancer having undergone tumour excision followed by free-flap reconstruction been reviewed here. Nine patients had tumour excision done robotically through intraoral route while neck dissection done with transverse neck crease incision. There is a problem of difficult flap inset in this group of patient. Two patients had intraoral excision of tumour followed by robotic neck dissection via retroauricular incision. With no incision directly on the neck, microvascular anastomosis is challenging in this set of patients. Free flap was used in all the cases to reconstruct the defect. Results: Successful reconstruction with free flap was done in all the cases with good outcome both functionally and aesthetically. Conclusion: Free-flap reconstruction is possible in robotic head-and-neck cancer surgery despite small and difficult access, but it does need practice and some technical modifications for good outcome.

Summary Objective Perineal defects are encountered ever more frequently, in the treatment of vulvar cancers or abdominoperineal resection. The surgical treatment of vulvar cancer leads to significant skin defect. The aim of the reconstruction is not to provide volume but rather to resurface perineum. We propose a new solution to cover the extensive skin defect remaining after excision. Methods We report 3 patients who underwent large excision for vulvar cancer, with lymph node dissection. For reconstruction, we performed 3 advancement flaps. Two V-Y flaps cantered on the infra-gluteal folds and based on pudendal perforator arteries were used to cover the postero-lateral parts of the defect. The third advancement flap from the superior aspect of the defect was a Y-V Mons pubis flap. Results The defects were successfully covered by the 3 flap technique. The first patient suffered a non-union that slowly healed by secondary intention. For the other cases, we used the same technique, but applied negative pressure wound therapy on the sutures, with excellent results. Conclusion The 3 flap technique is a simple and reliable method and the donor site morbidity is minimal. It can be realised without changing the position of the patient after tumour excision, and does not require delicate perforator dissection. This surgical option can be easily applied, allowing better management of these cases.

Purpose Overall local recurrence of oral squamous cell carcinoma (OSCC) is estimated at 20%. Incomplete primary tumour excision contributes to localised postsurgical recurrence of OSCC. The purpose of this study was to report on patient outcomes following resection of OSCC using Narrow Band Imaging (NBI). Materials and methods Patients with OSCC requiring resection were visualised under conventional white light (WL) then NBI using an Olympus NBI ENF-VQ nasendoscope with CLV-180 light source and processor (Olympus Medical Systems, Tokyo, Japan). OSCC tissue was resected to the NBI-defined surgical margins, and patients followed for a minimum of 5 years postsurgery to assess local recurrence rate (LRR) and disease-free survival (DFS). Results Of the 20 patients recruited for this study, one patient (5%) declined follow-up. At the latest follow-up period (up to 7 years postsurgery), 14 of 19 patients (73.68%) were alive with no recurrence. Two patients (10.53%) had died from metastatic disease with no local recurrence, one patient (5.26%) had died from disease with local recurrence, and two patients (10.53%) had died disease-free from other causes. In total, 16 of 19 patients (84.21%) who were followed for a minimum of 5 years were still alive and had not developed local recurrence. Only one patient developed local recurrence. Five-year DFS was 84.21% and LRR was 5.26%. Conclusion Resection to NBI-defined margins improves survival rates and decreases recurrence rates of OSCC compared to traditional methods and should be adopted as the new gold standard for determining mucosal surgical margins for treatment of oral cavity cancer. These promising results have set the scene for a multicentred randomised controlled trial comparing NBI to WL currently underway.

Sarcomas are a group of rare malignant tumours of the connective tissues. They can occur in almost any location, but more frequently in the extremities. The occurrence of sarcomas in the head and neck region is less than 1%. We are presenting a case report of a very large cranial sarcoma. Gross total tumour excision was done with pedicle skin graft and titanium mesh cranioplasty. The excised tumour weighed approximately 1.1 kg. Histopathological examination showed primitive intermediate-sized tumour cells arranged in sheets, nests and cords with focal palisading. Postoperative MRI done 2 weeks post surgery showed no evidence of residual tumour.

Vulval/vaginal teratomas are rare occurrences in newborns. We report a case of a neonate that was born with a vulva teratoma, a rectovestibular anomaly, and a bifid T12 vertebra. To our knowledge, this combination is the first to be reported in the literature. The patient had a tumour excision in conjunction with a Primary Posterior Sagittal Anorectoplasty (PPSARP). She had post-operative complications of a wound breakdown that was managed conservatively. She is now being followed up on out-patient basis.

Laissez-faire following excision of peri-ocular tumours has been described, but is not universally well established. We describe our experience with laissez-faire for managing medial canthal defects following tumour excision and compare our outcomes with full thickness skin grafts. Retrospective comparative case series of 68 patients who underwent reconstruction of a medial canthal defect using laissez-faire with sutured Sorbsan (LFS) (n = 36) or a full thickness skin graft (FTSG) (n = 32) at the same centre. Tumour diagnosis, defect size, time taken to epithelialise, functional and cosmetic outcomes, complications, follow-up duration and any secondary interventions were recorded. Basal call carcinoma was the most common neoplasm excised (63/68, 93%). Defect size ranged from 7 × 5 mm to 25 × 10 mm. Mean time for wound epithelialisation in LFS group was 33 days. Mean duration of follow-up was 32 months (range 1-80 months) for LFS and 30 months (range 6-60 months) for FTSG. Good functional and cosmetic outcomes were achieved in all 68 patients. Review of clinical photographs showed epicanthic fold in 2 patients and visible scar in 1 patient in the LFS group and 3 cases of hypopigmented scar and 7 hypertrophic scars in the FTSG group. No cases required secondary intervention. There were no cases of postoperative infection. LFS in the medial canthal region is less likely to lead to hypertrophic scarring or cicatricial sequelae compared to FTSG (p = 0.02). Both techniques are associated with excellent functional and aesthetic outcomes even for larger defects.

Gastrointestinal stromal tumours (GISTs) are uncommon mesenchymaltumours that originate from the interstitial cells of Cajal (ICC). As thesetumours are difficult to distinguish from gastrointestinal smooth muscletumours using standard histological techniques, their true prevalencemay be underestimated. Metabolic and systemic consequences of GISTsare not well described in any species. More rarely, neoplasms withhistological and immunohistochemical features similar to GISTs mayoccur outside the gastrointestinal tract, so-called Extra-gastrointestinalStromal Tumours (EGIST). EGISTs have never been described in theveterinary literature. In this article we present and describe clinicalfindings, management and treatment of two dogs with clinicalhypoglycaemia induced by histologically confirmed GIST and EGIST.Hypoglycaemia resolved immediately and long-term after tumourexcision. To the authors’ knowledge this is the first report ofhypoglycaemia associated with a canine GIST and the first case report ofan EGIST in the dog.

BACKGROUND: Goal-directed fluid therapy (GDFT) improved patient outcomes in various surgical procedures; however, its role during mass brain resection was not well investigated. AIM: In this study, we evaluated a simple protocol based on intermittent evaluation of pulse pressure variation for guiding fluid therapy during brain tumour resection. METHODS: Sixty-one adult patients scheduled for supratentorial brain mass excision were randomized into either GDFT group (received intraoperative fluids guided by pulse pressure variation) and control group (received standard care). Both groups were compared according to the following: brain relaxation scale (BRS), mean arterial pressure, heart rate, urine output, intraoperative fluid intake, postoperative serum lactate, and length of hospital stay. RESULTS: Demographic data, cardiovascular data (mean arterial pressure and heart rate), and BRS were comparable between both groups. GDFT group received more intraoperative fluids {3155 (452) mL vs 2790 (443) mL, P = 0.002}, had higher urine output {2019 (449) mL vs 1410 (382) mL, P < 0.001}, and had lower serum lactate {0.9 (1) mmol versus 2.5 (1.1) mmol, P = 0.03} compared to control group. CONCLUSION: In conclusion, PPV-guided fluid therapy during supratentorial mass excision, increased intraoperative fluids, and improved peripheral perfusion without increasing brain swelling.

Background Periocular malignancy is common and in most cases will undergo excision with pre-determined margins and subsequent histological examination. Intraoperative margin control (IOMC) modalities such as fast frozen section (FFS), fast paraffin (FP) and Mohs micrographic surgery (MMS) are being increasingly widely used, though there is a lack of information regarding utility. The aim of this study was to survey members of the British Oculoplastic Surgery Society (BOPSS) to determine attitudes and access to different modalities of IOMC. Methods A 12-question online survey was disseminated via an e-mail to full members of the BOPSS. The survey was hosted using Qualtrics software via the University of Sussex. Results The overall response rate was 64 of 165 (38.8%). MMS was readily available in a neighbouring trust to 23 of 64 respondents (35.9%). Seven respondents (10.9%) reported no regional access to MMS. Twenty-nine members had readily available access to FFS (45.3%) and 37 of 64 to FP (57.8%) in their own institution. There is variation in what tumour types would be considered appropriate for IOMC, though most thought clinically ill-defined (morphoeic) basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) should undergo one form of IOMC (90.6% and 81.3%, respectively). Conclusion This study highlights variation in availability and utilisation of IOMC amongst oculoplastic surgeons and in different regions of the UK. While the exact place of IOMC in periocular tumour excision is debated, there is a consistent view that it should be available for some tumours. Greater consistency in provision may improve patient outcomes.